YOGA FOR DIABETES

 Regular YOGA practice can help reduce the level of sugar in the blood, along with lowering blood pressure, keeping a weight check, reducing the symptoms and slowing the rate of progression of diabetes, as well as lessening the severity of further complications. Let’s see how.

Like for most lifestyle diseases, stress is one of the major reasons for diabetes.It increases the secretion of glucagon hormones in the body, responsible for increasing blood glucose levels. Consistent practice of yoga asanas (body postures), pranayamas (breathingexercises)and a few minutes of daily meditation can help reduce stress in the mind and body. This, in turn, reduces glucagons and can also help improve insulin action.

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      The practice of yoga is also proven to reduce weight as well as control increasing weight, which is particularly important to keep diabetes in check. Sun Salutation and Kapal Bhati pranayama are one of the best ways to weight loss.

KAPAL BHATI PRANAYAMA

SUN SALUTATION

Diabetes can also be worsened with the occurrence of high blood pressure, or hypertension. Yoga asanas, such as the Corpse Pose, Bridge Pose, Child Pose, and Yoga Nidra are all helpful in controlling hypertension.

CORPSE POSE

Other yoga postures that are helpful in diabetes include Vajrasana (kneeling pose), Shoulder Stand, Plow Pose, Lying-Down Body Twist, Bow Posture, Two-LeggedForward Bend, and Sitting Half-Spinal Twist.

Lying-Down Body Twist

     Nadi Shodhan Pranayama is also good for diabetics. It helps release stress and flush out toxins from the body. Another excellent technique to combat diabetes is a unique breathing technique, Sudarshan Kriya, designed by Sri Sri Ravi Shankar. It has helped several diabetics across the world reduce blood glucose levels and control their condition from getting worse.

Nadi Shodhan Pranayama

A few minutes of regular meditation practice also acts as an excellent stress-buster for the mind and body. Interestingly, while stress is the major cause of diabetes, the condition in turn results in patients getting highly stressed about it, which further aggravates the problem. It has also been observed that most diabetics lose self-confidence and end up brooding over their condition. This is where meditation can help – restoring their confidence levels so that they gain the strength to fight the condition and live well.

  Craving for sweets is a common occurrence in diabetes. Regular practice of meditation can help drop such cravings to a large extent.

Source : The Art Of Living

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Lean Type 2 Diabetes Mellitus : Management Challenges in Indian Subcontinent

Corresponding Author: Dr. Anuj Maheshwari, MD, FIACM, FICP, FACP, FACE, FRCP(London) Professor & Head, General Medicine, BBD University,Lucknow-226022, India

Biography : Dr. Anuj Maheshwari is a General Physician and Diabetologist in Vikas Nagar, Lucknow and has an experience of 21 years in these fields. Dr. Anuj Maheshwari practices at Sri Hari Kamal Diabetes Heart Clinic in Vikas Nagar, Lucknow. He completed MBBS from Motilal Nehru Medical College in 1991, MD - General Medicine from King Georges Medical College, Lucknow University in 2000 and FIACM from Indian Association Of Clinical Medicine in 2013. He is a member of Indian Medical Association (IMA). 

Lean type 2 diabetes can be identified with low body massindex(BMI) with raised waist hip ratio in presence of type 2 diabetes mellitus. They are difficult to be identified until they are not met with complications. Although, it is much lesser prevalent in Indian population than caucasians, but it’s impact is stronger. 15 % western world population is lean type 2 diabetes mellituswhen 55% is obese. In India it is 3.5 percent only when 63 percent are with their ideal bodyweight. It involves greater risk as Indian tends to develop similar cardiovascular risks at lesser BMI what others develop on being obese because of peculiar phenotype which includes abdominal adiposity and much higher fat content at any BMI.  Dietary pattern with higher carbohydrates intake and lack of physical activity further complicates the outcome. Although it is more commonly seen in those diagnosed in old age but in India, as occurrence of type 2 diabetes has been predated a decade, so lot of youngsters are getting type 2 diabetes mellitus at lower or normal BMI. They are not typically similar to those in rest of the world. They do not carry the benefits of being lean type 2 diabetic like high HDL cholesterol and low occurrence of coronary artery disease (CAD).  

Conspicuously lean type 2 diabetes routinely presents with peripheral neuropathy, high incidence of retinopathy with markedly lesser incidences of hypertension, nephropathy and CAD as co morbidities. Severe basal hyperglycemia is seen with no or least weight gain even when it is treated. They are characterized with high level of glucokinase in circulation and hyperactive metabolic state in liver which is responsible for excess utilization of insulin in its first pass. Their lesser weight is accredited of fast carbohydrate metabolism and characterized with high C-peptide level without 

. Contrary to this, Indian lean type 2 diabetic is a peculiar phenotype that carries all risks of obesity at normal or lower body weight with hyperinsulinemia progressing gradually towards poor beta cell reserve. Lean type 2 diabetes is supposed to be associated with malnutrition but Indian type 2 lean diabetes has no relation with malnutrition.

Because of its unique characteristics of abdominal adiposity with higher insulin resistance  with characteristic dyslipidemia, Indian phenotype poses different challenges of management. Of course they should be differentiated from Type 1 Diabetes Mellitus and Latent Autoimmune Diabetes of Adult (LADA). Despite being lean type 2 diabetic, they are slow metaboliser of carbohydrate with slow disposal rate of glucose, low level of adipokines, high level of leptin and triglycerides presenting with impaired insulin secretion and insulin resistance together. Apart from this they poses serious management challenges impending cardiovascular risks because of higher content of abdominal adiposity with visceral fat at any level of BMI. Increased waist circumference with high waist hip ratio at any level of BMI is important marker of this peculiar phenotype which is attributed of certain genetic factors.

Same level of glucose challenge causes higher glycemic level in asian Indians than Caucasians. An important management challenge arises when glycoselated hemoglobin i.e. HbA1c is not only primarily contributed by post prandial hyperglycemia when it is reaching closer to target but actually in Indians type 2 diabetics, post prandial glycemia continues to remain of primary importance to be controlled together with basal hyperglycemia when HbA1c is far away from target. Therefore management requires lot of focus on post prandial correction in Indian phenotype. High carbohydrate content of food is an important cause. Apart from this few environmental factors like increasing physical inactivity, insomnia, stress, fast food challenges apart from existing challenges of high carbohydrate diet, play significant role in making type 2 DM management complex in Indian phenotype.  

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Target The Octet To Treat Right

Corresponding Author: Dr. Rishad Ahmed, Associate Professor, Department of Medicine, KPC Medical College & Hospital , Kolkata, West Bengal 700032, India

Biography : Dr Rishad Ahmed has special interest in Diabetes & Metabolic disorders. He completed his MD in Internal Medicine from the prestigious Rajiv Gandhi University of Health Sciences , then Diploma and Fellowship in Diabetes with distinction, a biographee in Who’s Who in Medicine & Healthcare & also accepted as boigraphee in Who’s Who of World 2018, a passionate teacher with several national & international publications Member : Association of Physicians in India, American Diabetes Association & Endocrine Society, US.

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The ominous octet is the pathophysiological core in the mechanism of diabetes. Every molecule has there different reference targets & and these targets are individually targeted at different times in the entire course & duration of diabetes. Metformin is an absolute necessity for treating diabetes if there are no contraindications. Newer class of drugs like SGLT2I & DPP4i have strengthened our treat-to-target goal for individual diabetic patients. As evident we know that reaching desired HbA1c goals is very difficult and we have to tailor our treatment protocols as per individual cases. We do not know which pathological pathway is affecting the individual and contributing to the diabetic status. SGLT2i target kidneys and DPP4i target the gut hormones in two different mechanisms all together. Its debatable which one may be used first but clearly if one goes by evidence & recommendations, diabetic with a background of cardiovascular disease must be initiated with an oral empagliflozin(SGLT2i) which is also approved by USFDA now. Why we are interested in diabetes and CVD is a well known and very important concept of the two to threefold increased risk of cardiovascular disease & cardiovascular death in patients with diabetes. Now we also know that almost three fourths of the patients with diabetes has minimal CAD when screened. Hence the burden of cardiovascular disease & death is so high in diabetes that the first choice should always be a SGLT2i over a DPP4i. Now DPP4i has its own advantages and compliment effects of SGLT2i in many different ways. Both have different target organs. It is known that whereas SGLT2i are known to increase the glucagon levels in blood, DPP4i are known to suppress glucagon levels by acting on the alfa cells, hence they complement each other well. The combination of SGLT2i/DPP4i not only complement each other well, this combination targets a lot of components in the ominous octet. Almost five components by DPP4i & two by SGLT2i. They are also known to halt the progression of chronic kidney disease by decreasing progression of albuminuria. Hence after metformin or even before using metformin this combination may give good treat-to-target benefits to the patients. Hence use SGLT2i/DPP4i combination in suitable patients. So using this combination will TREAT EARLY & TREAT HARD.

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Heart Disease & Diabetes Relation

Why Is Heart Disease So Common in People With Diabetes?

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Diabetes by itself is now regarded as the strongest risk factor for heart disease; however, a variety of mechanisms—not solely blood glucose levels—most likely come into play. The blood vessels in patients with diabetes are more susceptible to other well-established risk factors, such as smoking, high cholesterol and high blood pressure, and more than 90% of patients with diabetes have one or more of these additional risk factors.

Some of the increased susceptibility to blood vessel damage that people with diabetes have could be due to the long-term effects of inadequate control of blood glucose levels on the tissues or as a result of other cell damage related to diabetes. There is also evidence that being overweight, having a sedentary lifestyle and poor blood glucose control contribute to the increased chance of high blood pressure and abnormalities in blood lipids (i.e., high cholesterol, high triglycerides and a low level of HDL cholesterol—the “good” cholesterol.

Research on the role of additional risk factors is being conducted. Evidence shows that patients with diabetes have an increased level of low-grade inflammation of their arterial lining, a process that initiates the blood vessel changes leading to heart disease. Some of the new tests to assess this inflammation are being evaluated, including C-reactive protein and homocysteine.

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How to Prevent or Delay Heart Disease :

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The best way to prevent or delay the development of cardiovascular disease is to prevent diabetes itself. People with increased risk for diabetes can be identified. A large National Institutes of Health-sponsored study, the Diabetes Prevention Program, and other studies have proven that modest weight reduction and a 30-minute exercise routine five days a week can reduce the development of type 2 diabetes over three years by more than 50%. Moreover, even people at risk for diabetes or those with prediabetes, in addition to those with diabetes, frequently have abnormalities in blood pressure and lipid levels that can be detected and treated to prevent cardiovascular disease.

Weight control and smoking cessation are two important lifestyle measures that have an impact on preventing heart disease. Studies show that even in overweight people, regular physical activity has major cardiovascular benefits.

In the last 10 years, large-scale research studies around the world have shown that optimal control of LDL cholesterol (the “bad” cholesterol) and blood pressure can prevent adverse cardiovascular outcomes by 30% to 50%. The American Diabetes Association and the American Heart Association recommend an LDL cholesterol goal in all adults with diabetes at less than 100 mg/dl. In people who already have heart disease, a more desirable LDL cholesterol goal should be less than 70 mg/dl, based on evidence from more recent studies. The blood pressure goal in all patients with diabetes is less than 130/80. In most patients with diabetes, reaching these targets for blood pressure could require two or more medications. Fortunately, we have safe and effective medications available to help patients meet their lipid and blood pressure goals.

In addition, good control of blood glucose levels and low-dose aspirin can add to these benefits. For A1C tests—a measure of average blood glucose levels over the preceding two to three months—the goal is less than 7%..

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Take Action

To sum up:  there's no totally certain way to avoid heart disease and circulation problems. But there are lots of things to do to cut your risk.

• If you smoke, stop. 
• Lose weight if you are overweight 
• Keep your blood pressure in the proper range 
• Get regular physical activity 
• Keep your blood fats and cholesterol levels in a healthy range 
• Keep your blood glucose under control

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